Pulmonary Artery Augmentation and Pulmonary Valve Replacement After Arterial Switch Operation

The arterial switch operation, combined with the LeCompte maneuver, is the treatment of choice for transposition of great arteries.

Right ventricular outflow tract (RVOT) obstruction remains one of the most frequently encountered long-term postoperative complications and is the most common cause for reintervention after an arterial switch operation.

The Patient

This video presents a case of twenty-year-old woman who had undergone an arterial switch operation and ventricular septal defect closure for a dual outlet right ventricle with Taussig-Bing anomaly in 2002. This time, the patient presented with residual right ventricular outflow tract obstruction and moderate-to-severe pulmonary regurgitation due to a dysplastic pulmonary valve.

Preoperative imaging showed narrowing of the RVOT at both supravalvular and subvalvular levels due to the anterior displacement of RVOT after the LeCompte maneuver. The narrowest RVOT measured 8.3 x 9.1 mm. The right pulmonary artery measured 10.4 x 6.8mm and the left pulmonary artery measured 7.8 x 7.6 mm. 

The procedure included a resternotomy, pulmonary valve replacement with the Magna Ease #25 bioprosthetic tissue valve, and pulmonary arterioplasty with a bovine pericardium patch.

The Surgery
 
To begin, cardiopulmonary bypass was initiated via right groin cannulation. Antegrade blood cardioplegia was infused via the root and the heart was arrested.

The main pulmonary artery (PA) was opened with incision extended distally to bilateral PA and proximally to subvalvular RVOT. Right ventriculotomy was then performed. The pulmonary valve was resected and excessive RVOT muscles were debrided.

Initial implantation of the biological prosthesis was then performed at the valvular level. However, due to the short length of the main pulmonary artery, difficulty in any future endovascular pulmonary valve procedures was anticipated. Therefore, the prosthesis was explanted and reimplanted at the subvalvular level, allowing adequate working length should future endovascular procedures be needed. 

Next, PA enlargement and RVOT reconstruction were performed. The length of the bovine pericardium was estimated. The bilateral PA and main PA were then patch-enlarged with bovine pericardium. The RVOT was then patch-closed with bovine pericardium.

Postoperatively, it was noted that the PA was well expanded with a significant reduction in RVOT pressure gradient. The patient was discharged home on postoperative day six.

References

1. Morgan, Conall Thomas et al. “Understanding the Mechanism for Branch Pulmonary Artery Stenosis after the Arterial Switch Operation for Transposition of the Great Arteries.” European heart journal cardiovascular imaging 18.2 (2017): 180–185. Web.
2. 2. Wiggins, Luke M. et al. “Arterioplasty for Right Ventricular Outflow Tract Obstruction After Arterial Switch Is a Durable Procedure.” The Annals of thoracic surgery 100.1 (2015): 122–128. Web.
3. 3. Cleuziou, Julie et al. “Incidence and Risk Factors for Right Ventricular Outflow Tract Obstruction after the Arterial Switch Operation.” The Thoracic and cardiovascular surgeon 67.1 (2019): 037–043. Web.

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